Breastfeeding

Revised 2020_2021

Sample Teaching Plan NURSING DX BEHAVIORAL

OBJ. CONTENT & SUPPORTING EBP

METHODS IMPLEMENTATION EVALUATION

Knowledge Deficit: r/t

wound care

Subjective (3):

• “I don’t know

how to take care

of my wound

when I go home”

• “I have never

had surgery

before”

• “How often will

have to change

the dressing?”

Objective (3):

• Client has abd

incision in RLQ

• Client is 1 day

post-operative

abd surgery

• Client RLQ abd

wound with

clean, dry gauze

dressing intact.

Cognitive:

Client will state

12 steps of

wound care by

D/C with 100%

accuracy

I. Wound care (Cognitive)

A. Importance

1. Ability to heal

2. Prevention of infect

Potter, Perry, Stockert, & Hall (2013).

B. Components

1. Removal of old drsg.

2. Inspection of wound

3. Cleansing of wound

4. Wound drsg.

C. Wound care

1. Wash hands with soap & water x

3 mins

2. Apply clean gloves

3. Remove drgs by touch outside only -

closing dirty section inwards.

4. Discard in plastic bag

5. Chg. Gloves 6.cleanse with 1/2

str. h2o2 & h2o. Allow to air dry

7. Open sterile gauze

package using sterile tech. Do not

touch inside of drsg.

8. Tear 2 strips of tape about

6"long.

9. Apply sterile drsg over incision

without touching incision with hands.

10. Apply tape to top

and bottom of drsg.

11.Discard used equip.

12.Wash hands.

1. One to one

discussion

2. pamphlets on

incision care

3. video on

incisional care

4. Written instructions

1.Nurse will assess

client's readiness to

learn, prior to initial

teach. Session

2.Nurse will establish

trusting relationship with

client on day one of

hosp.

3. Nurse will review

concepts of wound care

while performing drsg.

chg for client each hosp

day.

4. Nurse will teach client

concepts for 10mins. 2 x

per shift until discharge.

5. Nurse will allow q &a

session at each teach

session until d/c

6.Nurse will validate

clients knowledge for

correctness at each 10

min teaching session 2

x per shift until

discharge.

Client able to state 8 of

12 steps of wound care

with 75% accuracy 2

times per shift by day 3 of

hosp. Teaching

interventions remain

ongoing.

Goal partially met

OR:

Client able to state all

12 of 12 steps of

wound care with 100%

accuracy by d/c

Goal met

Revised 2020_2021

NURSING DX BEHAVIORAL OBJ. CONTENT &

SUPPORTING EBP METHODS IMPLEMENTATION EVALUATION

Knowledge Deficit: r/t

wound care

Affective: Client will

discuss feelings

re: wound care by

D/C

I. Feelings re: wounds

A. Fear re: Ability to heal

B. Queasiness regard

necessity to touch area

C. Possible

repulsiveness by Self &

S/O

D. Worry about infection

II. Validity of feelings

A. Normality of

B. initial feelings

C. Ability to cope

after exposure

1. One : one

discussion

2. Group process

3. Journal keeping

4. Role playing

1.Nurse will assess

client's readiness to

learn, prior to initial

teach. Session

2.Nurse will establish

trusting relationship with client on day one of hosp.

3. Nurse will discuss

possible feelings client

may have regarding

wound care at each

drsg. chg

4.Nurse will encourage

client to verbalize

feelings regarding

wound care throughout

dressing changes - 2x

per shift until discharge.

5.Nurse will allow q&a

session at each teach

session until d/c

6.Nurse will validate

clients feelings regarding

wound care at each

teaching session 2x

/shift until discharge.

7.Nurse will encourage

s/o participation in

discussion of feelings

regarding wound care 2x

per shift at drsg chg

throughout hosp. stay

8.Nurse will contact

support group for post

hosp. Care to cont.

interventions.

Client able to discuss

feelings one to one during

each drsg change 2x per

shift by 2nd hosp day

client unable to discuss

feelings in group process.

Continue one on one disc.

Utilize journal keeping instead

of group process for remainder

of hosp. Stay. S/O willing to

participate in one on one disc.

By 2nd hops day. Teaching

interventions remain ongoing.

Goal: partially met

OR

Client able to discuss

feelings and states

confidence in wound care; “I

don’t feel queasy when

touching my wound and feel

confident in taking care of

my wound”

Goal: met

Revised 2020_2021

NURSING DX BEHAVIORAL

OBJ. CONTENT & SUPPORTING EBP

METHODS IMPLEMENTATION EVALUATION

knowledge Deficit:

r/t wound care

Psychomotor:

client will

demonstrate the

14 steps of

wound care by

D/C

with 100% accuracy

I. Wound care

(Psychomotor)

A.Wound care

1. wash hands with soap &

water x3 mins.

2. apply clean gloves

3.remove drgs by touch

outside only -closing dirty

section inward. examine

drsg. For drainage - color

amt, smell, consistency

4.discard in plastic bag

5.remove. Gloves

6.rewash hands

7.Apply sterile gloves

according to sterile glove

technique

8.cleanse with 1/2 str. h2o2

& h2o. Using sterile cotton

tip applicators clean in one

direction only allow to air dry

9. Open sterile gauze

package using sterile

tech. Do not touch inside

of drsg.

10. Tear 2 strips of tape

about 6"long.

11. Apply sterile drsg over

incision without touching

incision with hand 12.Appply

tape to top and bottom of

drsg.

13. Discard used equip.

14. wash hands

1. Demonstrate with

return demonstration

1.Nurse will assess

clients readiness to

learn, prior to initial

teach session

2.Nurse will establish

trusting relationship with

client on day one of hosp

3.Nurse will demonstrate

wound care 2x per shift

on 1st day of hosp.

4.Nurse will allow q&a

session at each teach

session until d/c

5.Nurse will encourage

client to participate in

wound care by holding

equip.and applying tape

at each dress. Chg.2x per shift on 2nd hosp day

6.Nurse will assist

client with performing

own wound care 1x on

3rd hosp day.

7.Clent will perform

entire wound care

procedure by 2nd drsg

chg on 3rd hosp day

8.Nurse will validate

clients knowledge for

correctness at each 10

min teaching session 2

x per shift until dischg

8.Nurse will provide

positive reinforcement for

efforts of client at each

drsg chg.2xper shift

Client able to demo 8 of

14 steps of wound care

with 50% accuracy by

1st drsg chg on 3rd

hosp.- teaching

interventions remain

ongoing.

OR:

Client able to

demonstrate 14 of 14

steps of wound care

with 100% accuracy

by d/c

Goal met

Implementation con't

9.Nurse will provide

client & S/O with written

instructions at d/c

Revised 2020_2021

References Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Elsevier Mosby